Provider Demographics
NPI:1629569546
Name:ATA, RONNIE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:A
Last Name:ATA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12601 WESTERN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-1777
Mailing Address - Country:US
Mailing Address - Phone:708-293-1903
Mailing Address - Fax:
Practice Address - Street 1:12601 WESTERN AVE STE B
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1777
Practice Address - Country:US
Practice Address - Phone:708-293-1903
Practice Address - Fax:708-293-1909
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist